N2010-0016 redacted for website
Transcript of N2010-0016 redacted for website
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FOR OFFICIAL USE ONLY
Audit Report
Reporting of Safety Mishaps
Releasable outside the Department of the Navy only on approval of the Auditor General of the Navy
N2010-0016 (revised)
12 March 2010
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7510
N2008-NIA000-0055
12 Mar 10
MEMORANDUM FOR DISTRIBUTION
Subj: REPORTING OF SAFETY MISHAPS (AUDIT REPORT N2010-0016)
Ref: (a) NAVAUDSVC memo 7510/N2008-NIA000-0055.000 dated
9 September 2008
(b) SECNAV Instruction 7510.7F, “Department of the Navy Internal Audit”
1. The report provides results of the subject audit announced in reference (a). Section A
of this report provides our findings and recommendations, summarized management
responses, and our comments on the responses. Section B provides the status of the
recommendations. Consolidated management responses for all recommendations were
submitted via the Commander, Naval Safety Center. The full text of management
responses is included in the Appendixes.
2. The following chart notes the action commands for each recommendation.
Command Finding No. Recommendation No.
Surgeon General of the Navy/Bureau of Medicine and Surgery
1
1, 2, & 3
Chief of Naval Operations (N09F)/Commander, Naval Safety Center
1,2 & 3
2,3,4,5,6,11,12,14,15, & 16
Commander, U. S. Fleet Forces Command 1 & 2 9,10, & 13
Commander, U. S. Pacific Fleet 1 & 2 9,10, & 13
Commander, Naval Installations Command 1 7 & 8
3. Actions taken by Chief of Naval Operations (N09F)/Commander, Naval Safety
Center, meet the intent of Recommendation 5; actions taken by Commander, Naval
Installations Command meet the intent of Recommendation 7. Therefore,
Recommendations 5 and 7 are considered closed.
4. Actions planned by the applicable commands meet the intent of
Recommendations 1-4, 6, and 8-16. Because Commander, U.S. Fleet Forces Command
and Commander, U.S. Pacific Fleet did not provide a target completion date for
Recommendation 13, we have assigned a target completion date to that recommendation
(see the finding and Section B). Because the target completion dates for
DEPARTMENT OF THE NAVY NAVAL AUDIT SERVICE 1006 BEATTY PLACE SE
WASHINGTON NAVY YARD, DC 20374-5005
Subj: REPORTING OF SAFETY MISHAPS (AUDIT REPORT N2010-0016)
. . . . . . . . .
Recommendations 6, 11, and 16 are more than 6 months in the future, we have assigned
interim target dates for those recommendations.
5. Recommendations 1-4, 6, and 8-16 are considered open pending completion of the
planned corrective actions, and are subject to monitoring in accordance with
reference (b). Management should provide a written status report on the
recommendations applicable to them within 30 days after target completion dates.
6. Please provide all correspondence to the Assistant Auditor General for Installations
and Environment Audits, XXXXXXXXXXXXXXXXXXXXXXXX, with a copy to the
Director, Policy and Oversight, XXXXXXXXXXXXXXXXXX. Please submit
correspondence in electronic format (Microsoft Word or Adobe Acrobat file), and ensure
that it is on letterhead and includes a scanned signature.
7. Any requests for this report under the Freedom of Information Act must be approved
by the Auditor General of the Navy as required by reference (b). This audit report is also
subject to followup in accordance with reference (b).
8. We appreciate the cooperation and courtesies extended to our auditors.
XXXXXXXXXXXXXXXX
Assistant Auditor General
Installations and Environment Audits
Distribution:
Surgeon General of the Navy/Bureau of Medicine and Surgery
Chief of Naval Operations (N09F)/Commander, Naval Safety Center
Commander, U. S. Fleet Forces Command
Commander, U. S. Pacific Fleet
Commander, Naval Installations Command
Copy to (next page)
FOIA (b)(6)
FOIA (b)(6)
Subj: REPORTING OF SAFETY MISHAPS (AUDIT REPORT N2010-0016)
. . . . . . . . .
Copy to:
UNSECNAV
DCMO
OGC
ASSTSECNAV FMC
ASSTSECNAV FMC (FMO)
ASSTSECNAV IE (DASN (S))
ASSTSECNAV MRA
ASSTSECNAV RDA
CNO (VCNO, DNS-33, N4B, N41)
CMC (RFR, ACMC)
DON CIO
NAVINSGEN (NAVIG-4)
AFAA/DO
i
Table of Contents
EXECUTIVE SUMMARY ................................................................................................ 1 Overview ..................................................................................................................................... 1
Reason for Audit .......................................................................................................................... 2
Noteworthy Accomplishments .................................................................................................... 2
Conclusions ................................................................................................................................. 2
Federal Managers’ Financial Integrity Act .................................................................................. 6
Corrective Actions ....................................................................................................................... 6
SECTION A: FINDINGS, RECOMMENDATIONS, AND CORRECTIVE ACTIONS ....... 8
Finding 1: Reporting of Personnel Safety Mishaps ................................................................... 8 Synopsis ....................................................................................................................................... 8
Discussion of Details ................................................................................................................... 9
Background .............................................................................................................................. 9
Audit Results ............................................................................................................................... 9
Medical-Safety Data Matching ................................................................................................ 9
Shore Visits ............................................................................................................................ 10
Reasons Mishaps Were Not Reported .................................................................................... 11
Effect ...................................................................................................................................... 13
Recommendations and Corrective Actions ............................................................................... 13
Finding 2: Reporting of Equipment Mishaps ........................................................................... 19 Synopsis ..................................................................................................................................... 19
Background ................................................................................................................................ 19
Audit Results ............................................................................................................................. 20
Recommendations and Corrective Actions ............................................................................... 22
Finding 3: WESS ........................................................................................................................ 25 Synopsis ..................................................................................................................................... 25
Background ................................................................................................................................ 25
Audit Results ............................................................................................................................. 25
Recommendations and Corrective Actions ............................................................................... 27
SECTION B: STATUS OF RECOMMENDATIONS ...................................................... 30
EXHIBIT A: BACKGROUND ........................................................................................ 33
EXHIBIT B: SCOPE AND METHODOLOGY ................................................................ 35 Scope ......................................................................................................................................... 35
Methodology .............................................................................................................................. 35
EXHIBIT C: ACTIVITIES VISITED AND/OR CONTACTED ......................................... 40
ii
APPENDIX 1: CONSOLIDATED MANAGEMENT RESPONSE .................................. 43
APPENDIX 12 ADDITIONAL MANAGEMENT RESPONSE TO SELECTED RECOMMENDATIONS ................................................................................................. 53
1
Executive Summary
Overview
The Department of the Navy’s (DON’s) Fiscal Year (FY) 2008 Risk Assessment
identified the underreporting of safety mishaps as a high-risk area.
Office of the Chief of Naval Operations (OPNAV) Instruction (OPNAVINST) 5102.1D,
“Navy [and Marine Corps] Mishap and Safety Investigation Reporting and
Recordkeeping Manual,” issued 7 January 2005, defines a mishap as any unplanned or
unexpected event causing death, injury, occupational illness, and material loss or damage.
A reportable mishap includes military on- and off-duty mishaps, as well as incidents
involving damage to Government property. Additionally, OPNAV requires that all afloat
fires (excluding small trashcan fires), floodings, collisions, and groundings be reported as
mishaps.
Per the OPNAVINST, mishaps are classified into three main categories (A, B, and C)
depending upon severity. Broadly defined, Class A mishaps involve death, permanent
total disability, or equipment damages exceeding $1 million. Class B and C mishaps are
those that involve all other injuries incurring greater than one lost workday or equipment
damage exceeding $20,000 but less than $1 million.
In addition, the instruction: (a) provides for standardized investigation, reporting, and
recordkeeping procedures for afloat and shore commands; and (b) requires that mishap
causal factors be identified to enable development of appropriate corrective actions to
help prevent mishaps. The Web-Enabled Safety System (WESS) is the official mandated
system for reporting and tracking all DON personnel and equipment mishaps. WESS is
managed and maintained by the Commander, Naval Safety Center
(COMNAVSAFECEN), who uses the data to identify mishap trends and to help develop
effective Navy-wide mishap prevention strategies, as well as to maintain safety statistics
and other information in support of Naval commands.
This audit focused on: (1) Class B and C non-combat mishaps occurring both on and
off-duty that involved active-duty, shore-based personnel; and (2) Class B and C
equipment mishaps afloat. The audit scope did not include aviation-related mishaps.
We performed the audit from 9 September 2008 through 16 October 2009. Conditions
noted existed during Fiscal Year (FY) 2006 through May 2008, and in some cases
continued through FY 2009, as noted in the report.
EXECUTIVE SUMMARY
2
Reason for Audit
This audit was performed to address concerns about mishap reporting identified in
DON’s FY 2008 Risk Assessment, which identified underreporting of safety mishaps as a
high risk. The stated vulnerability was that current reporting patterns underrepresented
the actual rate of safety events. Our overall objective was to verify that the Navy’s
current safety mishap reporting processes were efficient and effective. This audit was
agreed to by the Chief of Naval Operations (CNO) Special Assistant for Safety Matters
(OPNAV N09F/COMNAVSAFECEN).
Noteworthy Accomplishments
All parties interviewed – most notably NAVSAFECEN, U.S. Fleet Forces Command
(USFFC), U.S. Pacific Fleet Command (COMPACFLT); Commander, Naval Surface
Forces; and afloat and shore command personnel we spoke with during the audit were
frank in discussing issues involving mishap reporting and why reports were not always
made, and offered many suggestions to help improve the Navy’s mishap reporting
processes. We also appreciate the assistance of personnel with the Navy and
Marine Corps Public Health Center (NMCPHC) under the DON Bureau of Medicine and
Surgery (BUMED) who provided support in obtaining medical treatment data needed to
identify potential reportable mishap-related injuries.
In addition, we want to acknowledge the proactive efforts of NAVSAFECEN in taking
actions on its own initiative and in response to the audit that went beyond what we
recommended, for example to release several ALSAFE messages to increase the
awareness of mishap reporting requirements; and during the audit submitting a Data
Sharing Agreement to BUMED for using restricted medical data to identify personnel
mishaps; working with Naval Warfare Development Command to include mishap
reporting requirements in casualty report (CASREP) guidance; and establishing a Data
Strategy Working Group to review the mishap reporting data set and eliminate
unnecessary data elements. Also, during the audit, Commander, Naval Installations
Command initiated systems changes to the Enterprise Safety Application Management
System (ESAMS) to provide complete verification of mishap reporting in accordance
with OPNAVINST 5102.1D.
Conclusions
We found that the Navy’s mishap reporting processes were inefficient and ineffective.
Specifically, Class B and C mishaps involving active-duty, shore-based military
personnel, and reportable afloat equipment damages and events, were not typically
captured and reported to NAVSAFECEN by the responsible commands. Additionally,
EXECUTIVE SUMMARY
3
the Navy did not have a link between safety reporting and medical treatment data to
identify potential personnel mishaps. As a result, the Navy’s official mishap reporting
system, the WESS, was incomplete, hampering the Navy’s ability to analyze mishap data,
identify trends and concerns, develop mishap prevention strategies, and take effective
corrective actions. We matched inpatient medical treatment data for active duty Navy
personnel from the NMCPHC’s Standard Inpatient Data Record (SIDR) inpatient medical
database to Class B and C mishap data from the NAVSAFECEN’s WESS database. The
medical treatment data was used to identify potential reportable mishap-related personnel
injuries. Our results showed that about 87 percent of the potential mishap-related injuries
were not reported in WESS.
We also conducted site visits at 25 shore activities to determine why the mishap-related
injuries identified to their command had not been reported. The percentage of mishaps
not reported at the sites visited ranged from 83 percent to 98 percent. Overall, mishaps
were not reported by an average of 95 percent (305 of 322) for the 25 shore activities
visited. These results confirmed that personnel mishaps at these locations are
significantly underreported. Class B and C mishaps went unreported for a variety of
reasons; however, the primary reason was that injured personnel and their supervisors
were often unaware of the reporting criteria, and were uncertain as to what injuries were
reportable. Therefore, the responsible command had no record or documentation of an
injury.
In some cases, shore commands under Commander, Naval Installations Command
(CNIC) reported the mishaps via the contractor-developed Enterprise Safety Application
Management System (ESAMS) -- a system that incorporates its own mishap reporting
capability; but the reports did not upload to WESS when the users did not have active
WESS accounts.
We also found that injuries sustained by personnel at a prior command and then
temporarily assigned to a Medical Hold Unit (MEDHOLD) or to a Transient Personnel
Unit (TPU) were not reported. This occurred because the prior command did not report
and/or the guidance was not clear as to which command’s responsibility it was to report.
The guidance addresses Permanent Change of Station (PCS) but not temporary
assignments to MEDHOLD or TPU. The guidance clearly states for “injuries occurring
during Permanent Change of Station (PCS) orders, it is the responsibility of the gaining
command to submit the mishap report…” It does not specifically address the prior
command’s responsibility to submit mishap reports for personnel temporarily assigned to
MEDHOLD or a TPU.
We obtained unclassified CASREP data to identify equipment mishaps that occurred to
assess how well equipment mishaps were being reported, based on consultation with
NAVSAFECEN, and to confirm whether the mishaps had been reported to
NAVSAFECEN. We performed three separate reviews of this data. First, we identified
26 equipment mishaps that occurred in the first quarter of FY 2008. We found that none
EXECUTIVE SUMMARY
4
of the 26 mishaps had been reported. We also identified a limited random sample of 10
equipment mishaps in FYs 2006 through 2008, and found that only 3 of the 10 had been
reported. We identified a third, expanded random sample of 30 equipment mishaps
occurring between FYs 2006 and 2008, and found that only 2 of the 30 mishaps had
actually been reported.
We then visited 20 Continental U.S. ships homeported on the East and West Coasts,
ranging from small patrol craft to aircraft carriers, to identify reasons that mishaps were
not being reported. Additionally, we reviewed all initial FY 2009 CASREPs issued by
each of the 20 ships we visited, and identified 10 more equipment mishaps, of which
none had been reported via WESS or to NAVSAFECEN as of May 2009. These results,
combined with those stated in the previous paragraph, confirm that equipment mishaps
were substantially underreported since at least FY 2006.
Based on the results of our reviews, we concluded that the Navy’s current processes and
procedures to ensure that Class B and C mishaps are captured and reported to
NAVSAFECEN using WESS are ineffective and inefficient. Without proper reporting
by Navy personnel and their commands, the NAVSAFECEN and Naval leadership are
unable to accurately assess the extent and nature of active-duty personnel, afloat
equipment, and other reportable afloat mishaps that are occurring, or to devise
appropriate solutions for minimizing associated hazards and resolving other causative
issues.
Similarly, the Navy did not establish internal controls to ensure that Afloat Safety
Officers were informed of equipment mishaps, and personnel in positions to initially
identify equipment mishaps were not trained on what constituted an equipment mishap.
Additionally, safety personnel considered NAVSAFECEN guidance on what constituted
a reportable equipment mishap to be too broad and unclear.
We also found that the Fleet units often did not consider Class B and C mishap reporting
to be a high priority, particularly in cases in which the Safety Officer function was
assigned as a collateral duty. Safety and applicable maintenance personnel were not
sufficiently trained or refreshed on what equipment and other mishaps required reporting
(i.e., in general, those related to fire, flooding, collisions, groundings, or exceeding
$20,000 in damage).
Compounding these situations were the difficulties that safety personnel experienced
trying to enter data into WESS once a mishap was identified, including constant data
refreshes and system timeouts, expiring passwords, problems locating Common Access
Card (CAC)-supported machines to use for data entry, and ships’ limited bandwidth.
While these issues were generally the result of DON information technology
requirements, all of these conditions resulted in a time-consuming data entry process that
required a modal average of 4 hours to complete one report for ships afloat.
EXECUTIVE SUMMARY
5
While this audit was in process, the Naval Audit Service also completed an audit on the
acquisition of a Navy-wide Risk Management Information System (RMIS). The RMIS
audit reported that DON did not have a single online management information system to
integrate and report all critical safety functional data, such as: mishap/injury reporting,
near-miss reporting, job hazard analysis, fire inspections/protection management, private
motor vehicle management, safety inspections, industrial hygiene, trend analysis, and
safety training. The report also stated that “there are about 26 independent safety
applications used to meet their [DON’s] safety reporting needs.” ESAMS is the only
safety application mentioned in our report. However, the fact that so many other safety
applications exist, supports the need for a corporate information system that brings all
DON information together for use in performing analyses and making management
decisions.
Command Ethics Program. During the audit, we also reviewed NAVSAFECEN’s and
NMCPHC’s ethics programs. We determined that the commands did have effective
ethics programs in place in terms of the systems, processes, and procedures required to
reasonably ensure compliance with DoD 5500.7-R, “Joint Ethics Regulation,” and
Executive Order 12674, “Principles of Ethical Conduct for Government Officers and
Employees.”
Communication with Management. Throughout the audit, we kept
OPNAV N09F/COMNAVSAFECEN, USFFC, COMPACFLT, CNIC, and the activities
and ships we visited, informed of the conditions noted as related to their individual
commands.
Specifically, we held meetings with OPNAV N09F/COMNAVSAFECEN to obtain his
endorsement of the audit (11 June 2008) and report on results (8 April 2009). We met
with the Executive Director, NAVSAFECEN to brief him during research
(12 August 2008) and to identify areas of specific concern, as well as to inform him of
audit results to date (11 June 2009). We also met with the Head, Epi Data Center,
NMCPHC, to obtain medical treatment data on active-duty personnel for comparison to
WESS data (13 November 2008).
As the audit fieldwork was being completed, we also met with USFFC, 02IG, Director,
Inspector General and Management Controls and N4S, Director, Fleet Safety, (6 May
2009); and Commander, COMPACFLT, represented by Commander, Naval Facilities
Pacific (NAVFACPAC) N01CE, (23 April 2009); to provide status briefs. Both USFFC
and COMPACFLT agreed with our findings and recommendations.
Following completion of our fieldwork, we met with the Deputy Assistant Secretary of
the Navy (Safety) (3 June 2009) and with the Director, Industrial Hygiene/Occupational
Health and Safety, BUMED (M44) (10 June 2009). Both Deputy Assistant Secretary of
the Navy (Safety) and BUMED (M44) agreed with our findings and recommendations.
EXECUTIVE SUMMARY
6
Since CNIC was also an action addressee for our potential recommendations, we briefed
CNIC, Deputy Special Assistant, N35 Safety/Shore Occupational Health, on the results of
our audit to date, and potential findings and recommendations, which CNIC also
supported (13 May 2009). In addition, on 3 August 2009, senior leaders of the Naval
Audit Service presented our preliminary audit results to the Under Secretary of the Navy,
Assistant Secretary of the Navy (Installations and Environment), and Deputy Assistant
Secretary of the Navy (Safety). Prior to the presentation, we sent copies of the briefing
material to the NAVSAFECEN, CNIC, and the Director of Safety, Commandant of the
Marine Corps.
Federal Managers’ Financial Integrity Act
The Federal Managers’ Financial Integrity Act (FMFIA) of 1982, as codified in Title 31,
United States Code, requires each Federal agency head to annually certify the
effectiveness of the agency’s internal and accounting system controls. In our opinion, the
conditions noted in this report may warrant reporting in the Auditor General’s annual
FMFIA memorandum identifying management control weaknesses to the Secretary of the
Navy.
Corrective Actions
To improve the efficiency and effectiveness of Class B and C mishap reporting and
reduce underreporting of mishaps, we made recommendations to the Surgeon General of
the Navy, OPNAV N09F/COMNAVSAFECEN, USFFC, COMPACFLT, and CNIC.
We recommended that the Surgeon General of the Navy (BUMED) direct the medical
community to provide medical treatment data to NAVSAFECEN; provide a Plan of
Action and Milestones, and obtain the funding necessary to accomplish this
recommendation. To OPNAV N09F/COMNAVSAFECEN and BUMED, we
recommended they determine and develop the best process for transferring and using
available electronic medical treatment data to identify reportable mishaps; provide a Plan
of Action and Milestones, and obtain the funding necessary to accomplish this
recommendation; and develop interim means of regularly obtaining medical treatment
data that will alert NAVSAFECEN of possible mishaps. We also recommended that
OPNAV N09F/COMNAVSAFECEN develop a process to use the medical treatment data
to notify commands of potential mishaps that require investigation and completion of a
mishap report, as appropriate; provide a Plan of Action and Milestones, and obtain
necessary funding to accomplish this recommendation. We also recommended that
OPNAV N09F/COMNAVSAFECEN develop and issue appropriate guidance that
requires shore based establishments and operating forces to incorporate comprehensive
safety mishap identification and reporting requirements for on- and off-duty injuries as
part of indoctrination training and safety stand downs.
EXECUTIVE SUMMARY
7
We recommended that USFFC and COMPACFLT establish standard fleet procedures
and controls to identify and capture equipment mishap information for reporting to
NAVSAFECEN and retain records of all reportable mishaps in accordance with
OPNAVINST 5102.1D, and provide all required equipment mishap reports to
WESS/NAVSAFECEN. We also recommended that the Fleet Commanders measure
performance and provide continuous oversight to ensure afloat commands are complying
with all mishap reporting requirements. Additionally, we recommended that
COMNAVSAFECEN submit change proposal for Naval Weapons Publication 1-03-1 to
Naval Warfare Development Command revising Casualty Report guidance to clearly
state that a mishap statement is required; provide server-based WESS onboard ships to
reduce time consuming online entry; and revise data requirements cited in OPNAVINST
5102.1D and data input requirements programmed into WESS to ensure that
requirements are reasonable and necessary based on the nature and severity of the event
being reported.
We recommended that CNIC take action to incorporate a receipt confirmation/validation
process into ESAMS; and measure performance and provide continuous oversight to
ensure shore commands and installations are complying with all mishap reporting
requirements. Finally, we recommended that OPNAV N09F/COMNAVSAFECEN
revise OPNAVINST 5102.1D guidance to:
Specify who is responsible for reporting injuries for personnel assigned to
MEDHOLD or to TPUs;
Clarify equipment mishaps that require reporting, particularly those involving
fire and flooding, and those where no personal injury is involve; and
Remove references to the WESS-Disconnected System (WESS-DS; an offline
disk used to upload WESS data) and update the NAVSAFECEN Web site to
remove the option to request a WESS-DS disk.
Management took or plans appropriate corrective actions on all the recommendations.
8
Section A:
Findings, Recommendations, and
Corrective Actions
Finding 1: Reporting of Personnel Safety Mishaps
Synopsis
Navy commands rarely reported Class B and C safety mishaps involving personnel injury
and/or lost workdays efficiently and effectively; and the Navy did not use medical
treatment data from medical treatment facilities (MTFs) to identify personnel mishaps as
required by the Department of Defense (DoD) and Navy guidance. The Navy’s current
reporting process requires individual service members to self-report any on- or off-duty
injuries to their responsible Navy command. Once the individual submits a report, the
command is responsible for creating a mishap report and submitting it into the
Web-Enabled Safety System (WESS). According to Navy guidance, WESS is the
official mandated system for reporting and tracking all Department of the Navy (DON)
personnel mishaps. Specifically, we found that 87 percent (3,649 of 4,208) of potential
mishap-related injuries for active duty Navy personnel occurring in Fiscal Years (FYs)
2006 through May 2008 were not reported in WESS. Those commands responsible for
reporting safety mishaps did not have procedures in place to ensure that reportable
mishaps were reported and recorded in WESS. DoD and Navy guidance requires injured
military personnel and their supervisors to report each mishap-related injury. Injured
personnel and their supervisors did not report mishaps because they were often not aware
of the reporting criteria, and were uncertain as to what injuries were reportable.
Additionally, it is our opinion that injured personnel have no vested interest in reporting
mishaps or in ensuring the DON’s official database contains an accurate and complete
record of mishaps for analysis and decisionmaking. Therefore, we concluded that
self-reporting alone is not efficient and effective in ensuring that Class B and C mishaps
involving personnel injury and lost workdays are reported in WESS.
We also found that injuries sustained by personnel at a prior command and then assigned
to a Medical Hold (MEDHOLD) or a Transient Personnel Unit (TPU) were not reported.
This occurred because the prior command did not report and/or the guidance was not
clear as to who was responsible for reporting. Additionally, because some users of the
Enterprise Safety Application Management System (ESAMS) were not aware that an
active WESS account was needed, some mishaps may not have been successfully
submitted to WESS. Although ESAMS may show that the mishap report was sent to
WESS, there is no validation or confirmation of receipt from WESS. As a result, the
SECTION A: FINDINGS, RECOMMENDATIONS, AND CORRECTIVE ACTIONS FINDING 1: REPORTING OF PERSONNEL SAFETY MISHAPS
9
total number of Class B and C mishaps the Naval Safety Center (NAVSAFECEN)
reports to Navy leadership is significantly underreported. Without complete and accurate
data, the extent of mishap problems cannot be known, the causes cannot be assessed, and
effective mishap prevention strategies cannot be developed or evaluated.
Discussion of Details
Background
Mishap reports are designed to provide Navy leadership with vital information needed to
develop effective preventive measures that can eliminate or reduce future mishaps.
DoD Instruction (DoDINST) 6055.7, “Accident Investigation, Reporting and
Recordkeeping,” 3 October 2000, as modified by Undersecretary of Defense for
Acquisition, Technology and Logistics (USD (AT&L)) Memo, “Injury Reporting
Requirements,” 20 February 2007, requires injured military personnel and their
supervisors to report each mishap-related injury, and requires the use of military medical
treatment information in identifying personnel mishaps.
Office of the Chief of Naval Operations (OPNAV) Instruction (OPNAVINST) 5102.1D,
“Navy and Marine Corps Mishap and Safety Investigation Reporting and Record
Keeping Manual,” dated 7 January 2005, requires all commands to investigate, report,
and maintain records of all mishaps; and requires identification and analysis of mishap
causal factors to develop appropriate corrective actions to prevent future mishaps.
Chapter 3 provides standardized mishap record keeping requirements and reporting
procedures. The instruction states that all Navy recordable/reportable mishaps shall be
reported electronically to NAVSAFECEN using WESS.
Audit Results
Medical-Safety Data Matching
The Navy does not have sufficient controls in place to capture mishap-related injuries in
cases where personnel report to a medical treatment facility or hospital. DoD Instruction
6055.7, as modified by the 2007 USD (AT&L) Memo, requires the use of medical
treatment reports in the identification of active-duty military personnel mishaps. The
results of our medical-safety data matching and site visits to 25 shore activities fully
support the need for the sharing of medical treatment data to identify mishap-related
injuries. Medical treatment data provides the first-line notification of a potential
mishap-related injury. Linking these two reporting systems is vital to reducing the
number of unreported mishaps involving active duty military personnel.
SECTION A: FINDINGS, RECOMMENDATIONS, AND CORRECTIVE ACTIONS FINDING 1: REPORTING OF PERSONNEL SAFETY MISHAPS
10
To determine the potential magnitude of underreported Class B and C active duty
personnel mishaps in the Navy, we obtained Fiscal Year (FY) 2006 through May 2008
inpatient medical treatment data from the Navy and Marine Corps Public Health Center
(NMCPHC) for active duty Navy personnel only. The NMCPHC medical treatment data
was used to identify potential reportable mishap-related personnel injuries. We also
obtained FYs 2006 through 2008 Class B and C mishap data from NAVSAFECEN’s
WESS database. Some of the records in WESS did not contain valid or complete Social
Security numbers (SSNs). The Naval Audit Service Data Analysis team initially
performed a combination of two matches on the data. First, the records in NMCPHC
database were matched by SSN/personnel identification numbers and event date to the
records in the WESS database. Next, records with invalid or incomplete SSNs in the
WESS database were matched to the records in the NMCPHC database by first name, last
name, and event date. The results of the two initial matches, combined, showed that 131
of the 4,208 NMCPHC potential mishap-related records were reported in
NAVSAFECEN’s WESS database. Of the 131 matches, 19 resulted from the first name,
last name, and event date match of records with invalid or incomplete SSNs. Therefore,
we concluded that invalid or incomplete SSNs would not have a significant impact on the
results.
Taking a different approach, we requested that the Data Analysis team perform a third
match of the two databases using data mining techniques to identify potential unreported
mishap-related personnel injuries. Using SSNs only, the medical treatment data from
NMCPHC was matched to the WESS Class B and C mishap data. Of the 4,208
NMCPHC potential mishap-related records, 559 records were included in
NAVSAFECEN’s WESS database and 3,649 records were not and were considered
unreported. By comparing the medical treatment data from NMCPHC to the WESS
Class B and C mishap data, we found that 87 percent (3,649 of 4,208) of the potential
mishap-related injuries were not reported in WESS.
Shore Visits
We selected a sample from the initial results of potential mishap-related injuries that were
not reported. These results consisted of 3,2111 unique Continental United States
(CONUS) records and the remaining records were Outside the Continental United States
(OCONUS). From the total number of unique CONUS records, we judgmentally
selected 25 shore activities to visit based on: (1) location of the Medical Treatment
Facility, (2) number of NMCPHC records by Unit Identification Code, and (3) percentage
of unmatched records by Unit Identification Code. Our objectives were to: (1) review
processes and procedures for identifying and reporting personnel mishaps; and
(2) determine why the potential mishap-related injuries identified to their command had
not been reported. The sample selected represented 11 percent of the unique unmatched
1 Subsequently, we determined that there could have been potentially as many as 3,536 CONUS records. However, the difference was
not significant to our judgmental sample and did not impact our audit results.
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CONUS NMCPHC records (359 of 3,211 records). We visited 10 activities in the
Hampton Roads area of Virginia (Norfolk/Virginia Beach/Portsmouth); 5 activities in the
Jacksonville and Mayport, FL area; 5 activities in San Diego, CA; and 5 activities in
Pearl Harbor, HI. Overall, mishaps were not reported by an average of 95 percent (305
of 322) for the 25 shore activities visited. The percentage of mishaps not reported at the
sites visited ranged from 83 percent to 98 percent. The results of our site visits confirmed
that Class B and C active duty personnel mishaps were significantly underreported.
Table 1 summarizes the results, by location, of the unmatched CONUS NMCPHC
records.
Table 1. Mishap Summary
Location
Unmatched NMCPHC Records
2
Misclassified3
Not Reportable Reportable
Reported to WESS
Not
Reported
Percent Not
Reported
Hampton Roads
189
24
165
10
155
94%
Jacksonville/ Mayport
19
1
18
3
15
83%
San Diego
99
7
92
3
89
97%
Pearl Harbor
52
5
47
1
46
98%
Total
359
37
322
17
305
95%
Reasons Mishaps Were Not Reported
Reliance on Self Reporting. Activities visited provided a number of reasons that
Class B and C mishap-related injuries were not reported. However, the primary reason
given was that injured personnel and supervisors were unaware of the reporting criteria,
and were uncertain as to what injuries were reportable. The current reporting process
requires individual service members to self-report any on- or off-duty injuries to their
responsible Navy command. Once the individual submits a report, the command is
responsible for creating a mishap report and submitting it into WESS. Since the
responsibility to report a mishap lies with the injured individual, many mishaps are often
not being reported, especially off-duty mishaps. In our opinion, that is because
individuals have no vested interest in reporting the mishaps and ensuring that the DON
has a complete and accurate record of all mishaps in the WESS database for analysis and
decisionmaking. Therefore, self-reporting is not efficient and effective in ensuring that
Class B and C mishaps involving personnel injury and lost workdays are reported in
WESS. For this reason, additional controls and processes are needed to improve mishap
reporting.
2 These records were selected from the initial results of potential mishap-related injuries that were not reported.
3 Chronic Injury, medical issue/condition, subsequent visit for prior reported mishap, injury received from direct enemy
action.
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Personnel generally receive indoctrination training when reporting to a new assignment,
and activities conduct periodic safety stand-downs. Responsible safety personnel stated
that they are only allowed a limited amount of time to discuss pertinent safety-related
information, and mishap reporting and identification are either never discussed or
discussed only briefly. Based on these results, all Navy personnel, both shore-based and
afloat, need specific training in mishap identification and reporting.
Responsibility. We also found that injuries sustained by personnel at a prior command
and then temporarily assigned to either a MEDHOLD or TPU were not reported. This
occurred because the prior command did not report and/or the guidance was not clear as
to which command’s responsibility it was to report this particular type of mishap.
OPNAVINST 5102.1D addresses Permanent Change of Station (PCS) but not temporary
assignments to a MEDHOLD or TPU. The guidance clearly states that for “injuries
occurring during Permanent Change of Station (PCS) orders, it is the responsibility of the
gaining command to submit the mishap report.” It does not specifically address the prior
command’s responsibility to submit mishap reports for personnel assigned to
MEDHOLD or TPU. The guidance should be clarified to address the prior command’s
responsibility for personnel assigned to MEDHOLD or TPU as a result of a mishap-
related injury.
Use of Other Systems. Additionally, 14 of the 25 activities visited used ESAMS to
report safety mishaps instead of the mandated WESS system. Ten of the 14 activities
were under the Commander, Naval Installation Command (CNIC) and were directed to
use ESAMS; while the other four activities elected to use ESAMS. Those activities using
ESAMS stated that it was more user-friendly than WESS. ESAMS can electronically
send mishap data from ESAMS to WESS; however, an active WESS account is required.
We found that 2 of the 14 activities using ESAMS were not aware that an active WESS
account was needed and believed that mishaps were automatically sent to WESS. These
2 activities had a total of 25 mishaps that were neither reported in ESAMS or WESS.
Had these activities entered the mishaps in ESAMS, the mishaps would not have
successfully transmitted to WESS because they did not have an active WESS account.
Also, ESAMS will not transfer reports to WESS until the mishap investigation is finished
and the report is completed. Although ESAMS may show that the mishap report was sent
to WESS, there is no validation or confirmation of receipt from WESS. As long as
ESAMS is used, a validation/confirmation process of receipt of mishap report is needed.
In a recent Naval Audit Service audit on the acquisition of a DON-wide Risk
Management Information System (RMIS), it was reported that “DON does not have a
single online management information system to integrate and report all critical safety
functional data such as: mishap/injury reporting, near-miss reporting, job hazard analysis,
fire inspections/protection management, private motor vehicle management, safety
inspections, industrial hygiene, trend analysis, and safety training.” The report also said
“that there are about 26 independent safety applications used to meet their [DON’s]
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safety reporting needs.” Other than ESAMS, none of the other safety applications, as
mentioned in the RMIS report, were cited as a reason for underreporting active duty
personnel mishaps at the activities we visited. However, the fact that so many other
safety applications exist supports the need for a corporate information system that brings
all the DON information together for use in performing analyses and making
management decisions.
Effect
As a result, the total number of Class B and C mishaps NAVSAFECEN reports to Navy
leadership is significantly underreported. Since the Navy uses mishap data to identify
trends and report safety data to Navy leadership, complete and accurate data is necessary.
Without complete and accurate data, effective mishap prevention strategies cannot be
developed or evaluated.
Recommendations and Corrective Actions
Our recommendations, summarized management responses, and our comments on the
responses are provided below. A consolidated management response to all the
recommendations was provided via the Commander, NAVSAFECEN
(COMNAVSAFECEN). COMNAVSAFECEN also provided an additional consolidated
management response with more information on the actions planned in response to
selected recommendations. The complete text of the responses is in the Appendixes.
To improve the reporting process for active duty military personnel mishaps, we
recommend that the Surgeon General of the Navy (Bureau of Medicine and Surgery
(BUMED)):
Recommendation 1. Direct the medical community to provide medical treatment
data to NAVSAFECEN in accordance with DoDINST 6055.7 as modified by
USD (AT&L) Memo dated 20 February 2007, that requires the use of medical
treatment information in the identification of mishaps. To ensure protection of patient
privacy, data provided should be that which is minimally necessary to accomplish the
authorized purpose.
Management response to Recommendation 1. Concur. The minimum data
necessary will be determined collaboratively with NAVSAFECEN and BUMED.
The working group will provide its recommendations by 1 March 2010. New
requirements will be incorporated into a modified Data Sharing Agreement with
TRICARE.
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Naval Marine Corps Public Health Center (NMCPHC) will provide the identified
and filtered data to NAVSAFECEN on a weekly basis commencing 1 April 2010,
until the automated feed is implemented.
Naval Audit Service comments on response to Recommendation 1. Actions planned by management (in response to this recommendation and
Recommendation 2) to work jointly to determine the medical data necessary
for identifying potential mishaps and implementing interim means of providing
the data to NAVSAFECEN, meet the intent of the recommendation.
We recommend that OPNAV 09F/COMNAVSAFECEN and BUMED:
Recommendation 2. Determine and develop the best process for transferring and
using available electronic medical treatment data to identify reportable mishaps.
Provide a Plan of Action and Milestones (POA&M) and obtain necessary funding for
accomplishment of this recommendation.
Management response to Recommendation 2. Concur. NAVSAFECEN
submitted a Data Sharing Agreement to the TRICARE Privacy Office via
BUMED. TRICARE Privacy Office has asked that Office of the Undersecretary
of Defense (Personnel and Readiness) (OSD) (P&R) approve the request. Upon
data access approval, OSD (P&R), TRICARE, BUMED, and NAVSAFECEN will
collaborate to determine the appropriate data transport mechanism and generate a
POA&M. OSD (P&R) has proposed the Defense Safety Enterprise System will
provide the interface for NAVSAFECEN. A POA&M will be developed and
approved by 1 April 2010.
Without knowing the full requirements for the electronic feed, a cost estimate and
subsequent funding request cannot be made. NAVSAFECEN is currently working
to identify out-of-cycle funding sources for this initiative.
Naval Audit Service comments on response to Recommendation 2. Actions
planned by management (in response to this recommendation and Recommendation
4) to obtain approval of the Data Sharing Agreement by OSD, further collaborate to
determine the appropriate data transport mechanism, and develop a POA&M for using
medical treatment data to notify commands of potential mishaps, meet the intent of
the recommendation. In subsequent communication, 6 January 2010, management
indicated the target approval date for the Data Sharing Agreement is March 2010. In
addition, actions planned by management to proactively identify out-of-cycle funding
sources for implementing the corrective actions also meet the intent of the
recommendation.
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Recommendation 3. Develop interim means of regularly obtaining medical
treatment data that will alert NAVSAFECEN of possible mishaps, until
Recommendation 2 is fully implemented.
Management response to Recommendation 3. Concur. See management
response to Recommendation 1. NAVSAFECEN is standing by to receive
medical treatment data from BUMED by the interim method until
Recommendation 2 is fully implemented. BUMED will task NMCPHC with
providing agreed-upon data to NAVSAFECEN. NMCPHC will commence
providing interim data on 1 April 2010.
Naval Audit Service comments on response to Recommendation 3. Planned actions meet the intent of the recommendation.
We recommend that OPNAV 09F/COMNAVSAFECEN:
Recommendation 4. For the interim and when Recommendation 2 is fully
implemented, develop a process to use the medical treatment data to notify commands
of potential mishaps that require investigation and completion of a mishap report, as
appropriate. Provide a POA&M for accomplishment of this recommendation.
Management response to Recommendation 4. Concur. NAVSAFECEN will
develop a POA&M for the interim and final solutions to notify commands of
potential mishaps that require investigation and completion of a mishap report, as
appropriate using medical treatment data provided by BUMED under
Recommendations 2 and 3. POA&M will be developed by 1 April 2010.
Naval Audit Service comments on response to Recommendation 4. Planned actions meet the intent of the recommendation.
Recommendation 5. Develop and issue appropriate guidance that requires
shore-based establishments and operating forces to incorporate comprehensive safety
mishap identification, and reporting requirements for on- or off-duty injuries as part
of indoctrination training and safety stand downs, and ensure personnel are fully
aware of all requirements.4
Management response to Recommendation 5. Partially concur.
NAVSAFECEN is not the custodian of the policy for indoctrination training and
safety stand downs. To meet the intent of the recommendation, NAVSAFECEN
will develop an instructional PowerPoint presentation and post it on the
NAVSAFECEN website by 1 March 2010 so that it is available to shore-based
and operating forces. Also, NAVSAFECEN will release an ALSAFE message
4 Note: This recommendation also relates to Fleet ships and carriers as well as shore activities. Ships also reported that
personnel as well as equipment mishap identification and reporting were not typically covered during indoctrination training or during safety stand-downs.
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outlining mishap reporting requirements and advocating that commands make the
PowerPoint presentation part of indoctrination training and use periodically during
safety stand downs.
Naval Audit Service comments on response to Recommendation 5.
Actions to develop training materials and make them accessible to shore and
operating forces for use during indoctrination training and safety stand downs
meet the intent of the recommendation. Subsequently, we determined that the
actions were completed as of 1 March 2010; therefore, we consider this
recommendation closed. It should also be noted that in management comments
to Recommendation 10, U.S. Fleet Forces Command (USFFC) and
Commander, Pacific Fleet (COMPACFLT) also plan to establish Fleet
procedures to ensure mishap reporting requirements are included in command
indoctrination training.
Recommendation 6. Revise OPNAVINST 5102.1D to specify who is responsible
for reporting injuries for personnel assigned to MEDHOLD or to TPUs, and ensure
responsible personnel are made aware of the change.
Management response to Recommendation 6. Concur. NAVSAFECEN will
develop clarifying language to address responsibilities for reporting injuries of
personnel assigned to MEDHOLD or TPUs. These responsibilities will be
promulgated through an ALSAFE message by 1 June 2010 and included in the 1
June 2011 revision of OPNAVINST 5102.1D.
Naval Audit Service comments on response to Recommendation 6.
Actions planned meet the intent of the recommendation. Because the target
completion date is more than 6 months in the future, we are assigning an
interim target date of 10 September 2010, and asking NAVSAFECEN to
provide us with a status report on the corrective actions at that time.
We recommend that Commander, Navy Installations Command (CNIC):
Recommendation 7. Take action to incorporate a receipt confirmation/validation
process into ESAMS and provide a POA&M for accomplishment of this
recommendation.
Management responses to Recommendation 7. Concur. Navy Installations
Command directed ESAMS contractor to initiate system changes to ESAMS that
provides verification of complete mishap reporting as required by
OPNAVINST 5102.1D. This action was completed 30 September 2009.
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Naval Audit Service comments on response to Recommendation 7. Actions
taken by management meet the intent of the recommendation. We consider this
recommendation to be closed.
Recommendation 8. Develop a set of performance measures and provide continuous
oversight to ensure CNIC regions and or installations are compliant with all mishap
reporting requirements.
Management response to Recommendation 8. Concur. CNIC established an
acceptable mishap reporting rate of 100 percent. Starting 15 April 2010,
Headquarters Safety (CNIC N35) will work with Regions to perform monthly
analyses of Region mishap reporting performance and ensure reporting
compliance using a standardized mishap query report. In addition, they will
monitor ESAMS and OPREP-3/SITREP message traffic to determine if mishaps
are being reported, and work closely with Region Commander Safety Staff to
rectify instances of noncompliance.
Naval Audit Service comments on response to Recommendation 8.
Planned actions meet the intent of the recommendation.
We recommend that Commanders, USFFC and PACFLT:
Recommendation 9. Develop a set of performance measures and provide continuous
oversight to ensure afloat commands are compliant with all mishap reporting
requirements.5
Management responses to Recommendation 9. Management’s planned actions
include issuing messages by 26 February 2010 to (a) direct afloat commands to
ensure safety personnel and all hands understand their responsibilities for
reporting injuries and property damage resulting from mishaps in accordance with
OPNAVINST 5100.19E; (b) remind afloat commands of OPNAVINSTs 5102.1D
and 5100.19E requirements to submit all reportable injury mishaps to
NAVSAFECEN via WESS, retain records for 5 years, and analyze mishap trends;
and (c) remind afloat type commanders (TYCOMS) and immediate superiors in
command (ISICS) of their responsibility to provide oversight of afloat commands
in accordance with stated guidance to ensure they conduct timely, thorough safety
investigations, retain mishap records for 5 years, and analyze mishap trends.
TYCOMS and ISICS shall conduct safety and occupational health oversight
inspections at a minimum of once every 3 years in accordance with USFFC and
COMPACLT 5100.7/5100.5E guidance. In addition, USFFC Code N4S and
COMPACFLT Code N01CE2 will implement a new evaluation step to assess
Fleet mishap reporting compliance by adding a review of medical logs and mishap
report records of selected commands during Safety and Occupational Health
5 This recommendation pertains to both personnel and equipment mishaps.
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Management Evaluations of TYCOMS to ensure all reportable injuries are
reported in WESS.
Naval Audit Service comments on response to Recommendation 9. Taken
as a whole, USFFC’s and PACFLT’s planned actions to remind commands of
their various oversight responsibilities as outlined in OPNAV, COMUSFFC,
and COMPACFLT guidance; their direction to ensure all hands understand
their responsibilities; and their action to add a review of medical logs and
mishap report records of selected commands during safety and occupational
health management evaluations of TYCOMS to ensure all reportable injuries
are reported in WESS to NAVSAFECEN, meet the intent of the
recommendation. In addition, the existing guidance noted in management’s
response (specifically OPNAVINST 5100.19 E) outlines the responsibilities
for setting safety, occupational, and health performance targets and measures.
It further states that these targets shall be reviewed annually. This aspect of the
guidance meets the intent of the recommendation. In subsequent
communication, management provided an updated target completion date of
31 March 2010.
19
Finding 2: Reporting of Equipment Mishaps
Synopsis
Responsible Naval commands afloat did not typically report Class B and C equipment
mishaps, including those involving fires and flooding, to COMNAVSAFECEN, as required
by the Office of the Chief of Naval Operations (OPNAV) Instruction 5102.1D.6 This
occurred for several reasons:
Maintenance personnel were often unaware of the need to report equipment mishaps
or were not trained sufficiently to identify what constitutes a reportable equipment
mishap;
The Fleet had not established specific mechanisms to alert Safety Officers and those
responsible for reporting to NAVSAFECEN that an equipment mishap had occurred;
and
The Fleet units considered the reporting criteria for equipment mishaps to be too
broad and unclear and frequently did not consider mishap reporting to be a high
priority, particularly in cases in which the Safety Officer function was assigned as a
collateral duty.
As a result, most equipment mishaps went unreported, making it difficult for the Navy to
identify mishap trends and take effective and efficient action to help prevent future
equipment mishaps. In cases in which similar types of equipment mishaps occur frequently,
such as electrical fires, the inability to properly capture associated mishap information and
develop appropriate solutions could ultimately affect mission readiness.
Background
OPNAVINST 5102.1D requires that all afloat fires (except small trash can fires not
involving injury to personnel), floodings, collisions, groundings, and any equipment
damage costs exceeding $20,000, be reported to NAVSAFECEN as mishaps. The
instruction does not require that these situations be reported only in the event of personnel
injuries.
Naval Warfare Publication (NWP) 1-03-1, published by the Naval Warfare Development
Command, addressed preparation of Casualty Reports (CASREPs), which are reports
describing equipment in need of immediate repair. This publication also provides a table
describing what information should be included in the remarks section of the CASREPs.
6 For the purposes of this report, the term “equipment mishap” is used to denote any instances of equipment damage
exceeding $20,000 or cases of fires, floodings, collisions, or groundings as defined by OPNAVINST 5102.1D.
SECTION A: FINDINGS, RECOMMENDATIONS, AND CORRECTIVE ACTIONS FINDING 2: REPORTING OF EQUIPMENT MISHAPS
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The NWP 1-03-1 guidance, while not presented clearly, indicates that CASREPs should
state “whether a mishap report is or is not required.”
Audit Results
Identifying Unreported Equipment Mishaps. To identify unreported Class B and C
equipment mishaps in the Navy based on consultation with NAVSAFECEN personnel, we
obtained unclassified databases of initial CASREPs issued by all surface ships and aircraft
carriers during FY 2006 through FY 2008 and reviewed all ship CASREPS for the first two
quarters of FY 2009. Databases were obtained from Commander, Naval Surface Forces
(CNSF). We then reviewed the databases in conjunction with NAVSAFECEN’s subject
matter expert to identify any equipment mishaps that required reporting (see Exhibit B,
Methodology section of this report for more detailed information on how we located the
reportable equipment mishaps).
We performed three CASREP sample reviews. First, we performed a preliminary review of
all 26 first quarter FY 2008 equipment mishaps that we identified to determine if the
mishaps had been reported to NAVSAFECEN via WESS, and whether the CASREPs
included a statement that a mishap report was or was not required. We found that none of
the 26 equipment mishaps had been reported in WESS. For the 26 CASREPs that required
a mishap report, 10 stated that “no mishap report was required.” The remaining CASREPS
did not include a mishap statement.
Following this review, we randomly sampled 10 identified equipment mishaps that occurred
between FYs 2006 through 2008 to confirm whether reporting was consistently low over the
period.7 We found that 3 of the 10 mishaps had been reported to NAVSAFECEN. Since
the 3 reported mishaps had occurred in the FYs 2006-2007 timeframe, we performed
another, larger random sample of these mishaps, selecting 10 from each fiscal year,
FY 2006 through FY 2008, for a total of 30, to gauge whether reporting had decreased over
the 3-year period. We found that one in FY 2007 and one in FY 2008 had been reported,
and 28 mishaps over the 3-year period had not been reported to NAVSAFECEN. Although
this sample did not indicate a downward trend, it does support that mishap reporting was
consistently underreported over the period reviewed.
Determining Processes Used to Identify and Report Equipment Mishaps. Since our
preliminary first quarter FY 2008 sample revealed relatively significant underreporting of
equipment mishaps (i.e., 0 of 26 had been reported), we selected 20 ships for review to
determine what processes they used to identify and report equipment mishaps and any
reasons they may have for not reporting them (see Exhibit B, Scope and Methodology, for
more information on how we selected the 20 ships). For each ship, we interviewed Safety
7 Note: these 10 were not part of the original 26 we reviewed for the first quarter of FY 2008 or part of the 30 that we
reviewed for the 3-year period between FY 2006 through FY2008.
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21
Officers (SOs), their assistants (ASSTs), and persons responsible for preparing CASREPS,
as they were available, to determine whether these personnel were aware of the equipment
reporting criteria and to determine how they identified and reported mishaps.
Additionally, to assess the shipboard processes, we reviewed 500 initial (i.e., no subsequent
or follow-on) FY 2009 CASREPs the ships had issued to date to determine whether the
CASREPs involved any reportable equipment mishaps and to see if the CASREPs included
a mishap statement. Results are described below:
Awareness and Training of Safety and Other Personnel. We found that SOs, ASSTs,
and maintenance personnel responsible for preparing CASREPs were rarely aware of the
equipment reporting criteria and were not specifically trained to identify equipment
issues that required reporting (affected 18 of 20 ships, or 90 percent). In general,
personnel believed that equipment mishaps need only be reported in those cases
involving injury.
When we reviewed 500 initial CASREPs issued during the first half of FY 2009 for the
20 ships we visited, we found that 10 of the 500 involved reportable mishaps; however,
none of the 10 had been reported to NAVSAFECEN. For these 10 reportable mishaps, 3
stated “no mishap report required,” and the remaining 7 did not contain any mishap
statement. Additionally, we found that, of the 500 shipboard CASREPs we reviewed,
168 (34 percent) included a statement of whether the mishap was reportable or not, and
332 (66 percent) did not contain the mishap statement.
Safety personnel interviewed stated that they and other shipboard personnel requiring
safety training, such as Division Petty Officers, either had not received any training to
identify equipment mishaps, or that training they received was insufficient. Personnel
also reported difficulties in getting into Naval Safety and Environmental Training Center
classes to obtain required training due to conflicts with the ship’s schedule, which often
resulted from increased deployments and operational tempo, as well as ship enrollment
quotas.8 At least 17 SOs/ASST SOs stated that training on mishap reporting they
received was minimal or insufficient.
Procedures in Place to Identify Equipment Mishaps. In addition to insufficient
training and awareness by the SOs and other pertinent shipboard personnel, we found
that 18 of 20 ships (90 percent) were unaware of criteria for reporting mishaps,
particularly equipment mishaps. For example, while we found that some SOs,
particularly those who were Operations Officers, did review CASREPs as well as
shipboard Situation Reports (SITREPs), in terms of safety mishaps Commander, Naval
Surface Forces stated that they typically only reviewed them to identify critical, or Class
A, mishaps. Since CASREPs, and perhaps more significantly, SITREPs, contain
8 Since verification of these issues was beyond the scope of this audit, we are unable to make recommendations in this
regard. However, these issues are identified as reasons that ships’ personnel stated for not being able to identify equipment mishaps, as well as mishaps in general.
SECTION A: FINDINGS, RECOMMENDATIONS, AND CORRECTIVE ACTIONS FINDING 2: REPORTING OF EQUIPMENT MISHAPS
22
valuable information that can be used to identify and prepare mishap reports, we
recommend that procedures be established for SOs to review such reports routinely for
required mishap reports or that other similar internal mechanisms for capturing
equipment mishap information be established.
Guidance for Determining Reportable Equipment Mishaps. In terms of identifying
equipment mishaps, NAVSAFECEN guidance on what constitutes a reportable
equipment mishap was considered by half (10 of 20) of ship safety personnel
interviewed, to be too broad and unclear, particularly in cases involving fire or flooding.
For example, personnel we interviewed were uncertain whether equipment that was
smoking or that had been burnt prior to being discovered (such as a burned-out electrical
component) were reportable mishaps. Personnel expressed similar confusion as to what
level of flooding actually required reporting and under what conditions. We concur that
OPNAVINST 5102.1D is unclear and lacks desired specificity in this regard.
Reporting Priority. We also found that the Fleet units frequently did not consider
mishap reporting, in general, to be a high priority, particularly in cases in which the SO
function was assigned as a collateral duty. This collateral duty was typically assigned to
Operations Officers or other key shipboard personnel who frequently reported being
overwhelmed with other more pressing work. At least 6 of 20 SOs we spoke with
actually stated that safety was a low priority given all the other duties they had to
perform. Additionally, although OPNAVINST 5102.1D requires that ships maintain all
safety mishap reporting records for 5 years, at least 9 of 20 had not retained records for
the required period.
As a result of these issues, Class B and C equipment mishaps are significantly
underreported in the Navy. If equipment mishaps are not reported when required, the Navy
loses the ability to identify recurring hazards and to develop appropriate corrective actions
and preventive measures to minimize future mishaps; the ultimate outcome is that Fleet
readiness may be compromised.
Recommendations and Corrective Actions
Our recommendations, summarized management responses, and our comments on the
responses are provided below. A consolidated management response to all the
recommendations was provided via COMNAVSAFECEN. COMNAVSAFECEN also
provided an additional consolidated management response with more information on the
actions planned in response to selected recommendations. The complete text of the
responses is in the Appendixes.
To improve the mishap reporting processes afloat, we recommend that
USFFC/COMPACFLT:
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Recommendation 10. Establish standard Fleet procedures and controls to identify and
capture equipment mishap information for reporting to NAVSAFECEN (for example,
require SOs to review all SITREPs and/or CASREPs to determine the need for mishap
reporting or implement other mechanisms to identify and capture equipment mishap
information).
Management responses to Recommendation 10. Concur. By 30 June 2010,
USFFC and PACFLT will establish and publish the following Fleet standard
procedures and controls for capturing equipment mishaps and to ensure mishap
reporting requirements are included in command indoctrination training: When
damaged equipment is discovered, department heads shall immediately notify the
Command SO of all cases of flooding or fire, and all equipment damage or losses
exceeding $50,000 as a result of mishap. The Command SO, in collaboration with
the department heads, shall conduct a mishap investigation, submit a mishap report
via WESS to NAVSAFECEN, retain the mishap records for a minimum of 5 years,
and analyze mishap trends.
Naval Audit Service comments on response to Recommendation 10. Per the
USFFC/COMPACFLT response, in October 2009 (which was after the time
period covered by our review), USD (AT&L) changed the minimum threshold for
Category C reporting to $50,000. Planned actions meet the intent of the
recommendation.
We recommend that OPNAV N09F/COMNAVSAFECEN:
Recommendation 11. Revise OPNAVINST 5102.1D guidance on reportable
equipment mishaps to clarify situations requiring reporting, particularly those involving
fire and flooding, and those where no personal injury is involved.
Management response to Recommendation 11. Concur. NAVSAFECEN is in
the process of better defining fire and flooding mishaps. Proposed definitions will
be vetted through TYCOMs for concurrence. New definitions will be promulgated
via an ALSAFE message by 15 May 2010 and subsequently included in the 1 June
2011 revision of OPNAVINST 5102.1D.
Naval Audit Service comments on response to Recommendation 11. Planned
actions meet the intent of the recommendation. Because the target completion
date is more than 6 months in the future, we are assigning an interim target date
of 10 September 2010, and asking NAVSAFECEN to provide us with a status
report on the corrective actions at that time.
Recommendation 12. Submit change proposal for NWP 1-03-1 to Naval Warfare
Development Command revising CASREP guidance to clearly state that a mishap
reporting statement is required.
SECTION A: FINDINGS, RECOMMENDATIONS, AND CORRECTIVE ACTIONS FINDING 2: REPORTING OF EQUIPMENT MISHAPS
24
Management response to Recommendation 12. Concur. NAVSAFECEN is
currently writing a change proposal to include a mishap reporting statement in
CASREP guidance. Naval Warfare Development Command agreed to make the
change once the proposal was submitted. The change proposal was forwarded to
Naval Warfare Development Command on 8 January 2010. NAVSAFECEN
estimates the message change will be out no later than 1 May 2010. Once the
message is promulgated, NAVSAFECEN will post the change on our Web page and
reference the change in our monthly safety digest message to the Fleet.
Naval Audit Service comments on response to Recommendation 12. Actions
planned meet the intent of the recommendation.
We recommend that USFFC/COMPACFLT:
Recommendation 13. Provide oversight to ensure that Fleet units retain records of all
reportable mishaps in accordance with OPNAVINST 5102.1D and provide all required
equipment mishap reports to WESS/NAVSAFECEN.
Management response to Recommendation 13. Management’s planned actions
include reviewing equipment mishap records of selected commands during
USFFC/COMPACFLT Safety and Occupational Health Management Evaluations of
TYCOMS. All afloat TYCOMS will be evaluated every 3 years.
Naval Audit Service comments on response to Recommendation 13. Actions
planned by management in response to this recommendation and
Recommendations 9 and 10 to direct afloat commands to ensure safety personnel
and all hands understand their responsibilities for reporting injuries and property
damage resulting from mishaps in accordance with OPNAVINST 5100.19E; and
to establish and publish Fleet standard procedures and controls for capturing
equipment mishaps and ensure mishap reporting requirements are included in
command indoctrination training respectively, meet the intent of the
recommendation. Since USFFC/COMPACFLT did not provide a target
completion date for this recommendation, we are using 30 June 2010, which was
the target completion date provided for Recommendation 10, as the target
completion date for this recommendation.
25
Finding 3: WESS
Synopsis
Safety personnel find NAVSAFECEN’s WESS cumbersome and time-consuming to use.
OPNAVINST 5102.1D requires that all mishaps be reported via WESS. However,
personnel at both shore and Fleet activities we visited described various issues that made
WESS difficult to use. Security issues pose particular problems for Fleet and shore users.
Additionally, because of the low and limited bandwidth available on ships, Fleet users felt
that data entry to the online WESS system, when made during deployments, was untenable,
taking hours or even days to complete. Data entries made by the Fleet when in port took
4 hours on average (mode) as reported by users – almost four times as long as the optimal
times some shore users reported (up to an 1 hour). Fleet users desired use of an offline
system, such as the WESS Disconnected System (WESS-DS) offered in
OPNAVINST 5102.1D and NAVSAFECEN’s Web site, but which is no longer a feasible
option due to resource issues and Privacy Act requirements. Finally, shore and Fleet users
also complained that too much information was being required for data input for Class B
and C mishaps, and not all of it was pertinent to the specific mishap being reported. As a
result of the various difficulties they faced using WESS and the perceptions that not all
information being requested was truly needed for various Class B and C mishaps, many
shore and Fleet mishaps may simply not have been reported, making it difficult for the
Navy to identify Class B and C mishap trends and take effective and efficient action to help
prevent future personnel and equipment mishaps.
Background
OPNAVINST 5102.1D requires that all mishaps be reported to NAVSAFECEN via WESS,
WESS-DS (an offline data-entry disk that is uploaded to WESS), or, in cases in which
WESS is not available, via Naval message. WESS-DS is designed for use by Fleet units and
activities that have low bandwidth or that do not have internet connectivity. However, in
2007, due to resource issues, NAVSAFECEN discontinued further modifications of
WESS-DS. Additionally, recent DON security requirements make the use of WESS-DS
unfeasible due to the Privacy Act information required for mishap reporting.
Audit Results
System Security Issues. During our initial audit research, we heard many comments about
problems with WESS usability. Based on these comments, we interviewed Fleet and ashore
safety personnel during the audit phase to learn more about their experiences using WESS.
We found that WESS users, in general, were extremely frustrated with the system.
SECTION A: FINDINGS, RECOMMENDATIONS, AND CORRECTIVE ACTIONS FINDING 3: WESS
26
Specifically, they cited constant page refreshes, frequent system time-outs, and the need to
update passwords every 60 days, as issues that made the system cumbersome to use. Both
shore and Fleet system users also expressed concerns about having to reestablish their
accounts after 60-days of inactivity. While these particular issues occurred because of
NAVSAFECEN’s implementation of DoD and Navy-mandated system information
technology security requirements, users were vocal about data input problems they
experienced as a result. Fleet users were particularly frustrated, explaining that the low and
limited bandwidth available on the ships made data entry under these conditions particularly
time consuming.
Low Bandwidth on Ships. While shore users also experienced many of the data entry
issues described above, Fleet users experienced additional problems caused by the low
bandwidth available on ships, which was similar to a low-speed dial-up connection.
Because of the low bandwidth, personnel on ships reported that it took about 2-4 hours to
complete a report that should generally only take about an hour or less to complete based on
some users’ optimal experiences that were reported to us.
WESS-DS. Fleet WESS users we interviewed who had a WESS-DS disk available to them
typically reported more positive experiences with WESS than users who did not have the
disk. Those SOs who did not have access to the disk universally requested that copies of
the disk be made available to them or suggested that another off-line system be developed
that would enable them to enter data offline and then upload the data to WESS during
periods of low bandwidth use.
However, while the option to request a WESS-DS disk is provided on the NAVSAFECEN
Web site and the option to use a disk is cited in OPNAVINST 5102.1D, due to difficulties
maintaining the disk versions and recent DoD/Navy-mandated security requirements,
WESS-DS is no longer a valid data entry method and further modifications of WESS-DS
have been discontinued. Since the disk version of WESS is no longer a viable alternative,
NAVSAFECEN is currently considering the possibility of installing a server-based
application on each ship that will function similarly to WESS-DS.
Data Input Requirements. In addition to slow and difficult data entry, over one-half of
safety personnel interviewed felt that WESS required input of too much information for
Class B and C mishaps (26 of 45 Fleet and shore users combined, or 58 percent). Shore and
Fleet users felt that too much information is required for reporting. Users also felt that they
were required to answer redundant questions or difficult-to-answer questions based on the
information they can reasonably obtain (for examples, reporters were required to know the
wind direction at the time of the accident, or if a person was injured while running, how
much experience a person had doing the “task” (i.e. running)). Although this information
may be pertinent for Class A and perhaps some Class B mishaps, some safety personnel
think that NAVSAFECEN is attempting to capture too much and sometimes unnecessary
information.
SECTION A: FINDINGS, RECOMMENDATIONS, AND CORRECTIVE ACTIONS FINDING 3: WESS
27
When we addressed these concerns with NAVSAFECEN personnel, they advised that
NAVSAFECEN is currently in the process of reviewing data elements to help streamline
data input efforts. Additionally, the Office of the Secretary of Defense (OSD) is conducting
a Defense-wide review to standardize required mishap reporting elements across the
services. Both of these efforts should help to address some of these issues raised by Fleet
users.
Other Issues. Still other Fleet personnel interviewed (8 of 20 users, or 40 percent) also
expressed concerns about, and questioned the need for, all the reports that they were
potentially required to prepare on a given incident, which could include preparation of
SITREPs, CASREPs, and Mishap Reports. While we were unable to confirm the validity of
these sentiments due to time constraints, we did note these as additional potential factors
affecting whether ships reported mishap incidents or not.
Taken in conjunction, these various system and security issues, as well as data entry
requirements, made WESS something that both shore and Fleet users tried to avoid. We
concluded that, confronted with a difficult and time-consuming system to use, personnel
may simply have chosen not to report some Class B, and particularly Class C, mishaps.
We noted that NAVSAFECEN is aware of many of these issues as reported by users, and,
in fact, requested that we attempt to quantify the scope of mishap underreporting in the
Navy and confirm reasons that commands did not report. While the majority of unreported
mishaps are caused by individuals and their supervisors not alerting SOs when incidents
occur, we believe that mishap reporting Navy-wide will also improve if WESS
improvements are made. These improvements include providing a server-based WESS
system onboard ships; refining data elements and input requirements to accommodate the
particular needs of shore and Fleet activities; tailoring data requirements to the severity of
the event (by eliminating data elements not necessary for Class B or C events); and,
potentially, incorporating data from SITREPs and/or CASREPs via electronic data capture
(i.e. to auto-populate data fields in WESS) if feasible to minimize duplication of effort when
reporting incidents.
Recommendations and Corrective Actions
Our recommendations, summarized management responses, and our comments on the
responses are provided below. A consolidated management response to all the
recommendations was provided via COMNAVSAFECEN. COMNAVSAFECEN also
provided an additional consolidated management response with more information on the
actions planned in response to selected recommendations. The complete text of the
responses is in the Appendixes.
SECTION A: FINDINGS, RECOMMENDATIONS, AND CORRECTIVE ACTIONS FINDING 3: WESS
28
We recommend that OPNAV N09F/COMNAVSAFECEN:
Recommendation 14. Revise OPNAVINST 5102.1D guidance to remove references
to WESS-DS and update the NAVSAFECEN Web site to remove the option to request
a WESS-DS disk.
Management response to Recommendation 14. Concur. WESS-DS is an interim
option available to deploying units until Navy Information Application Product
Suite (NIAPS) becomes available. Until then, WESS-DS provides a useful tool for
reporting mishaps. Management estimates WESS will enter into the NIAPS
pipeline on 1 October 2010. Additionally, the NIAPS program office will determine
the delivery schedule to meet the data protection requirements. They estimate the
schedule and determination will occur by 31 January 2011 and POA&M by
1 February 2011. References to WESS-DS will be removed from OPNAVINST
5102.1 in the 1 June 2011 revision. Status reports will be provided by 1 July 2010
and 1 January 2011.
Naval Audit Service response to Recommendation 14. Actions planned meet
the intent of the recommendation.
Recommendation 15. Establish a Plan of Actions and Milestones (POA&M) for
providing server-based WESS onboard ships to reduce time consuming online entry
(server will transmit during non-peak periods).
Management response to Recommendation 15. Concur. The initial capability is
through NIAPS as indicated in response to Recommendation 14. NIAPS currently
does not meet DoD requirements to fully protect data with public key infrastructure
(PKI) access controls. NAVSAFECEN will work with PMA 240 to determine the
earliest NIAPS release that will provide sufficient protection of Health Insurance
Portability and Accountability Act (HIPAA) and safety-privileged information. The
current estimate and earliest possible date that this recommendation can be
implemented is 1 October 2010 for testing and 1 June 2011 for delivery. A detailed
POA&M will be developed and delivered when notified by PMA 240 that NIAPS
will support PKI requirements. In the interim, NAVSAFECEN is modifying WESS
to utilize technology to operate in a more efficient asynchronous mode.
Additionally, WESS will utilize authoritative data sources to minimize the entry of
data by all users. Status reports will be provided by 1 July 2010 and 1 January 2011.
Naval Audit Service comments to Recommendation 15. Actions planned meet
the intent of the recommendation.
Recommendation 16. Review data requirements cited in OPNAVINST 5102.1D and
data input requirements programmed into WESS to ensure that requirements are
reasonable and necessary based on the nature and severity of the event being reported.
SECTION A: FINDINGS, RECOMMENDATIONS, AND CORRECTIVE ACTIONS FINDING 3: WESS
29
Management responses to Recommendation 16. Concur. NAVSAFECEN
established a Data Strategy Working Group in early 2009 with the intent of
reviewing the full mishap reporting data set and eliminating unnecessary data
elements. This review will be completed by 1 March 2010. NAVSAFECEN will
hold discussions with applicable Echelon II and III commands by 1 September 2010
and revise OPNAVINST 5102.1D to reflect the new data set and other required
policy changes by 1 June 2011.
Naval Audit Service comments to Recommendation 16. Planned actions meet the
intent of the recommendation. In subsequent communication, NAVSAFECEN indicated
that the review of the mishap reporting data set will be completed by 1 May 2010, and
that discussions with applicable Echelon II and III commands will be held by
1 November 2010. Because the final target completion date of 1 June 2011 is more than
6 months in the future, we are assigning an interim target date of 10 September 2010,
and asking NAVSAFECEN to provide us with a status report on the corrective actions at
that time.
30
Section B:
Status of Recommendations
Recommendations
Finding9
Rec. No.
Page No.
Subject Status10
Action
Command
Target or Actual
Completion Date
Interim
Target Completion
Date11
1 1 13 Direct the medical community to provide medical treatment data NAVSAFECEN in accordance with DoDINST 6055.7 as modified by USD (AT&L) Memo dated 20 February 2007 that requires the use of medical treatment information in the identification of mishaps. To ensure protection of patient privacy, data provided should be that which is minimally necessary to accomplish the authorized purpose.
O Surgeon General of the Navy (BUMED)
4/1/10
1 2 14 Determine and develop the best process for transferring and using available electronic medical treatment data to identify reportable mishaps. Provide a Plan of Action and Milestones (POA&M) and obtain necessary funding for accomplishment of this recommendation.
O OPNAV N09F/ COMNAVSAFECEN/BUMED
4/1/10
1 3 15 Develop interim means of regularly obtaining medical treatment data that will alert NAVSAFECEN of possible mishaps, until Recommendation 2 is fully implemented.
O OPNAV N09F/ COMNAVSAFECEN/BUMED
4/1/10
1 4 15 For the interim and when recommendation 2 is fully implemented, develop a process to use the medical treatment data to notify commands of potential mishaps that require investigation and completion of a mishap report as appropriate. Provide a Plan of Action and Milestones (POA&M) for accomplishment of this recommendation.
O OPNAV N09F/ COMNAVSAFE
CEN
4/1/10
9 / + = Indicates repeat finding.
10 / O = Recommendation is open with agreed-to corrective actions; C = Recommendation is closed with all action
completed; U = Recommendation is undecided with resolution efforts in progress. 11
If applicable.
SECTION B: STATUS OF RECOMMENDATIONS
31
Recommendations
Finding9
Rec. No.
Page No.
Subject Status10
Action
Command
Target or Actual
Completion Date
Interim
Target Completion
Date11
1 5 15 Develop and issue appropriate guidance that requires shore based establishments and operating forces to incorporate comprehensive safety mishap identification and reporting requirements for on- or off-duty injuries as part of indoctrination training and safety stand downs, and ensure personnel are fully aware of all requirements.
C OPNAV N09F/ COMNAVSAFE
CEN
3/1/10
1 6 16 Revise OPNAVINST 5102.1D to specify who is responsible for reporting injuries for personnel assigned to MEDHOLD or to TPUs, and ensure responsible personnel are made aware of the change.
O OPNAV N09F/
COMNAVSAFECEN
6/1/11 9/10/10
1 7 16 Take action to incorporate a receipt confirmation/validation process into ESAMS and provide a POA&M for accomplishment of this recommendation.
C CNIC 9/30/09
1 8 17 Develop a set of performance measures and provide continuous oversight to ensure CNIC regions and or installations are compliant with all mishap reporting
requirements.
O CNIC 04/15/10
1 9 17 Develop a set of performance measures and provide continuous oversight to ensure afloat commands are compliant with all mishap reporting requirements.
O USFFC/COMPACFLT
3/31/10
2 10 23 Establish standard Fleet procedures and controls to identify and capture equipment mishap information for reporting to NAVSAFECEN (for example, require SOs to review all SITREPs and/or CASREPs to determine the need for mishap reporting or implement other mechanisms to identify and capture equipment mishap information).
O USFFC/COMPACFLT
6/30/10
2 11 23 Revise OPNAVINST 5102.1D guidance on reportable equipment mishaps to clarify situations requiring reporting, particularly those involving fire and flooding, and those where no personal injury is involved.
O OPNAV N09F/COMNAVSAFECEN
6/1/11 9/10/10
SECTION B: STATUS OF RECOMMENDATIONS
32
Recommendations
Finding9
Rec. No.
Page No.
Subject Status10
Action
Command
Target or Actual
Completion Date
Interim
Target Completion
Date11
2 12 23 Submit change proposal for Naval Weapons Publication (NWP) 1-03-1 to Naval Warfare Development Command revising CASREP guidance to clearly state that a mishap reporting statement is required.
O OPNAV N09F/COMNAVSAFECEN
5/1/10
2 13 24 Provide oversight to ensure that Fleet units retain records of all reportable mishaps in accordance with OPNAVINST 5102.1D and provide all required equipment mishap reports to WESS/NAVSAFECEN.
O USFFC/COMPACFLT
6/30/10
3 14 28 Revise OPNAVINST 5102.1D guidance to remove references to WESS-DS and update the NAVSAFECEN Web site to remove the option to request a WESS-DS disk.
O OPNAV N09F/COMNAVSAFECEN
6/1/11 7/1/10
3 15 28 Establish a Plan of Actions and Milestones (POA&M) for providing server-based WESS onboard ships to reduce time consuming online entry (server will transmit during non-peak periods).
O OPNAV N09F/COMNAVSAFECEN
6/1/11 7/1/10
3 16 28 Review data requirements cited in OPNAVINST 5102.1D and data input requirements programmed into WESS to ensure that requirements are reasonable and necessary based on the nature and severity of the event being reported.
O OPNAV N09F/COMNAVSAFECEN
6/1/11 9/10/10
33
Exhibit A:
Background
In response to the 2008 Navy-wide Risk Assessment, underreporting of safety mishaps
was identified as a high risk. Cited as Risk number 8C1 in the 2008 Assessment, this risk
was similar to Risk number 8C3, submitted by the Navy Inspector General (IG) during the
2007 Navy-wide Risk Assessment. Based on these continuing identified high risks, we
performed this audit to assess the scope of mishap underreporting in the Navy and to
determine reasons that mishaps were not being reported. This audit was endorsed and
supported by senior Navy management, including Chief of Naval Operations (CNO)
N09F/Commander, Naval Safety Center (NAVSAFECEN).
Undersecretary of Defense for Acquisition, Technology and Logistics (USD (AT&L))
policy memorandum “Injury Reporting Requirements,” dated 20 February 2007, requires
injured military and civilian personnel and their supervisors to report each mishap-related
injury, and requires use of medical treatment and civilian personnel compensation reports
in the identification of personnel mishaps.
Office of the Chief of Naval Operations (OPNAV) Instruction (OPNAVINST) 5102.1D,
“Navy and Marine Corps Mishap and Safety Investigation Reporting and Record
Keeping Manual,” issued 7 January 2005, (a) provides standardized investigation,
reporting and recordkeeping procedures for afloat and shore mishaps and hazards; and (b)
requires that mishap causal factors be identified to develop appropriate corrective actions
to prevent future mishaps.
OPNAVINST 5102.1D defines a mishap as any unplanned or unexpected event causing
death, injury, occupational illness and material loss or damage. Mishaps also include
injuries that result in lost work time or work restrictions; material loss or damage; as well
as all instances of fire (except small trashcan fires that do not involve personnel injury),
floodings, groundings, and collisions. Mishaps are formally classified as categories A, B,
or C, depending upon severity.
In general, Class A mishaps involve death, extreme disability or disfigurement, or
equipment damages exceeding $1 million. Class B mishaps are generally defined as
mishaps in which the resulting total cost of damages to Department of Defense (DoD) or
non-DoD property is $200,000 or more, but less than $1 million; an injury and/or
occupational illness resulting in permanent partial disability; or when three or more
personnel are hospitalized for inpatient care (beyond observation) as a result of a single
mishap. Class C mishaps are generally defined as mishaps in which the resulting total
cost of damages to DoD or non-DoD property is $20,000 or more, but less than $200,000;
nonfatal injuries that caused any loss of time from work beyond the day or shift on which
it occurred; or a nonfatal occupational illness that caused loss of time from work or
EXHIBIT A: BACKGROUND
34
disability at any time. Because Class A mishaps are typically well-reported, this audit
focused primarily on Class B and C mishaps.
Military personnel are required to report both on- and off-duty mishaps as well as
mishaps that occur to equipment under their responsibility, as described in OPNAVINST
5102.1D. Supervisors then typically advise the Safety Office and the Safety Office
creates a mishap report. Mishap reports are then submitted to the NAVSAFECEN in one
of four ways: (1) directly through the Web-Enabled Safety System (WESS); (2) via
WESS-Disconnected System (DS) upload to WESS (shipboard use only); (3) via Naval
message for those who do not have internet access; or (4) via the Enterprise Safety
Application System (ESAMS), which is used by shore-based activities under the
Commander, Naval Installations Command (CNIC) and others utilizing ESAMS
contracts.
NAVSAFECEN uses the resulting data to identify mishap trends and to develop solutions
for mitigating potential safety hazards.
35
Exhibit B:
Scope and Methodology
Scope
The audit covered Navy-wide reporting of safety mishaps by ashore and afloat
commands, excluding the aviation and submarine communities, but including Naval
Aircraft Carriers. We focused on Class B and C mishaps. Specifically, we reviewed
safety mishaps related to shore-based active duty inpatient injuries and illnesses and
equipment mishaps afloat. We visited the shore activities and Fleet commands listed in
Exhibit C. Our original scope focused on Class B and C personnel and equipment
mishaps. However, we also tested Fiscal Years (FYs) 2006 through 2008 and the first
two quarters of FY 2009, Class A mishaps to ensure that all of the Class A mishaps we
identified had been reported.
Methodology
We evaluated internal controls and reviewed compliance with applicable regulations. We
performed preliminary reviews to determine the potential scope of unreported
shore-based active-duty personnel and ship-based equipment mishaps.
Personnel Mishaps
To assess the potential magnitude of unreported active-duty personnel Class B and C
mishaps, we coordinated with the Department of the Navy Bureau of Medicine and
Surgery (BUMED) and the Navy and Marine Corps Public Health Center (NMCPHC)
under BUMED, to obtain inpatient medical treatment data for active duty Navy personnel
for the period of FY 2006 through May 2008. We also obtained FY 2006 through
FY 2008 Class B and C mishap data from the Naval Safety Center’s (NAVSAFECEN’s)
Web-Enabled Safety System (WESS). Both sets of data were uploaded to the Naval Audit
Service (NAVAUDSVC) Data Analysis team using the NAVAUDSVC Secure Upload
Component. Some of the WESS data had either no Social Security number (SSN) or a
bad SSN. Using data mining techniques, the Data Analysis team initially performed a
combination of two matches on the data. First, they matched the records in the NMCPHC
database to the records in the WESS database using SSN/personnel identification numbers
(IDs) and event date. Next, they matched the records in the NMCPHC database to the
records in the WESS database with invalid or incomplete SSNs using first name, last
name, and event date. When the results of the two initial matches were combined, we
found that 131 of the 4,208 NMCPHC potential mishap-related records were reported in
EXHIBIT B: SCOPE AND METHODOLOGY
36
NAVSAFECEN’s WESS database. Only 19 of 131 matches resulted from the first name,
last name, and event date match of records with invalid or incomplete SSNs. The results
of these two matches were summarized by Unit Identification Code (UIC).
Taking a different approach, we requested that the Data Analysis team perform a third
match of the two databases using data mining techniques to identify potential unreported
mishap-related personnel injuries. The Data Analysis team matched the records in the
NMCPHC and WESS databases by SSN only. The ID field in the NMCPHC database
was matched to the SSN field in the WESS database to identify records not reported in
NAVSAFECEN’s WESS database. Of the 4,208 NMCPHC potential mishap-related
records, 559 records were included in NAVSAFECEN’s WESS database and 3,649
records were not and were considered unreported. By comparing the medical treatment
data from NMCPHC to the WESS Class B and C mishap data, we found that 87 percent
(3,649 of 4,208) of the potential mishap-related injuries were not reported in WESS.
We used the initial summary results provided by our Data Analysis team and
judgmentally selected 25 shore activities to visit. We selected 10 activities in the
Hampton Roads area of Virginia (Norfolk/Virginia Beach/Portsmouth), 5 activities in the
Jacksonville and Mayport, FL area, 5 activities in San Diego, CA, and 5 activities in
Pearl Harbor, HI. At each activity, we interviewed responsible safety personnel to
determine their level of experience regarding mishap reporting, training received,
knowledge of mishap reporting criteria, and reviewed processes and procedures for
identifying and reporting personnel mishaps. We also reviewed what processes and
controls they had in place to ensure that mishaps were properly reported to
NAVSAFECEN.
Equipment Mishaps
To assess the scope of unreported shipboard equipment mishaps, based on consultation
with NAVSAFECEN, we obtained unclassified data on initial (we did not review any
follow-on) Casualty Reports (CASREPs) submitted for the first quarter of FY 2008,
covering all surface ships and aircraft carriers. We reviewed all records in this database
to identify equipment mishaps that should have been reported to NAVSAFECEN. We
did this by performing key word searches of more than 20 different terms related to a
reportable event. Terms searched included, but were not limited to, fire, smoke, burn,
collide, collision, flood, grounding, and variations of the words and associated terms.
After extracting records that met our search criteria, we coordinated with
NAVSAFECEN subject matter experts to determine whether the CASREPs we extracted
involved reportable mishaps. Following this initial confirmation of which reports
involved mishaps, we conferred with shipboard inspectors at the Board of Inspection and
Survey to see whether they agreed with the identified mishaps. After reaching agreement
EXHIBIT B: SCOPE AND METHODOLOGY
37
on which records involved reportable mishaps, we then coordinated with NAVSAFECEN
to validate whether the mishaps had actually been reported in WESS.
Subsequent to this review, we obtained similar unclassified CASREP data for FYs 2006
through 2008 and, using data mining techniques, conducted additional key word searches
to extract records of potentially reportable mishaps. Again, we conferred with
NAVSAFECEN subject matter experts to identify actual, reportable mishaps. Based on
consultation with the NAVAUDSVC statistician, we then completed a limited review of
10 randomly sampled equipment mishaps occurring over the 3-year time period to
confirm that reporting was consistently low over the period. Per NAVSAFECEN’s
request, we performed a third random sample of 10 records per fiscal year (a total of
30 randomly identified mishaps) to assess whether mishap underreporting was becoming
progressively worse over time.
After completing our preliminary reviews, we judgmentally selected 20 ships (see
Exhibit C). We conducted onsite interviews at selected ships in four different locations –
two Continental East Coast locations and two Continental West Coast locations, in
coordination with the Commander Naval Surface Forces/Commander Naval Air Forces,
Inspector General’s Office. Our objectives were to determine how mishaps were
identified and reported as well as to determine reasons that both safety and general
personnel may not be reporting mishaps.
Our goals in selecting ships for review were to (1) target ships and locations that showed
up in our initial review as having unreported equipment mishaps; (2) include a variety of
ship types and sizes; and (3) include representative ships with a collateral duty Safety
Officer (SO) assigned, and those with a full-time SO assigned.
We met with personnel from five homeported ships at each of the four locations:
Norfolk/Virginia Beach, VA; Mayport, FL; San Diego, CA; and Pearl Harbor, HI. The
20 ships visited represented all hull types except auxiliary and mine warfare (these
vessels were not available during the time of our scheduled site visits), and ranged from
small patrol craft (PC) to aircraft carriers (CVN). The 20 ships represent about
11 percent of the Fleet vessels within our audit scope (20 divided by 178), based on data
published on the Naval Vessel Registry Website as of 20 April 2009.
For the 20 ships we reviewed, we ascertained whether the SO and Assistant (ASST) SOs
were aware of reporting of both personnel mishaps and equipment mishaps as described
in OPNAVINST 5102.1D. Additionally, we obtained safety personnel’s’ input as to how
activity personnel in general were informed of the need to report mishaps, including what
relevant training they received. We also obtained copies of any training materials, local
instructions and published standard operating procedures governing mishap reporting that
the activities and ships used.
EXHIBIT B: SCOPE AND METHODOLOGY
38
To gauge the scope of the ships’ workload, we identified the number of personnel
serviced by each shipboard SO, identified the number of division safety petty officers
assigned on the ship and, for those ships having SOs assigned as a collateral duty,
inquired into the approximate number of hours the SOs and ASSTs spent performing
safety-related duties on board the ship. Although their input was generally testimonial
and lacked documented support, this information was requested to assess the level of
priority currently assigned to the ships’ safety program and thus potentially to the ships’
mishap reporting processes.
In addition to the SOs and ASST SOs, we interviewed independent duty corpsman (IDC)
personnel on each ship to find out how they coordinate with their ship’s SO to report
personnel injuries. We also reviewed available Accident and Injury (A&I) reports and
sick call logs generated from the Shipboard Automated Medical System for the first two
quarters of FY 2009.
Since we are not medical experts, we reviewed A&I reports and the sick call logs only for
obvious types of Class B and C injuries that would require a mishap report, such as
broken limbs and injuries involving auto accidents. We also assessed whether the A&I
reports and/or sick call logs indicated that the individual had received more than 24 hours
of lost time due to the injury. Based on this conservative review, we identified injuries
that should have been reported as mishaps. Where we had questions or concerns, we
conferred with IDC and SO personnel to confirm the nature of the injuries. Once we
confirmed the reportable injuries, we determined whether the ship had submitted a
mishap report. Additionally, we coordinated with NAVSAFECEN to validate whether
WESS actually contained the associated report.
To determine how equipment mishaps were identified, we queried the SOs and ASST
SOs as well as personnel responsible for preparing equipment CASREPs. Additionally
since CASREPs guidance shown in the Naval Weapons Publication (NWP) 1-03-01
provides that CASREPs should include a statement in the remarks section that a mishap
report is or is not required, we checked all FY 2009 initial CASREPs issued by the ship
to date, to confirm whether this statement was being included. This same step was also
performed for all FYs 2006 through 2008 CASREPs we reviewed.
Again, since we did not have sufficient expertise to properly assess all of the equipment
issues recorded in the CASREPs, we relied on our laymen’s experience to review
CASREPs, as well as comparison to similar incidents that had been identified as
reportable based on our CASREPs reviews performed in conjunction with
NAVSAFECEN and Board of Inspection and Survey. Once we determined that the
CASREPs identified reportable mishaps, we coordinated with NAVSAFECEN to
confirm whether the WESS database contained the required WESS reports.
EXHIBIT B: SCOPE AND METHODOLOGY
39
Finally, we also queried the various interviewees as to: (1) reasons that personnel and
management, including those assigned to perform safety responsibilities were not
reporting all mishaps; (2) issues they experienced with reporting mishaps to
NAVSAFECEN and with using WESS; and (3) recommendations they had for improving
the mishap reporting process.
After conducting all interviews and completing our review, we prepared summary
spreadsheets to identify and assess significant issues affecting mishap reporting within
the Navy.
We conducted this performance audit in accordance with Generally Accepted
Government Auditing Standards. Those standards require that we plan and perform the
audit to obtain sufficient, appropriate evidence to provide a reasonable basis for our
findings and conclusions based on our audit objectives. We believe that the evidence
obtained provides a reasonable basis for our findings and conclusions based on our audit
objectives.
40
Exhibit C:
Activities Visited and/or Contacted
Office of the Assistant Secretary of the Navy, Installations and Environment (Safety),
Arlington, VA
Commander, Naval Safety Center, Norfolk, VA*
Commander, Naval Installations Command*
Bureau of Medicine and Surgery, Washington DC*
Naval and Marine Corps Public Health Center, Portsmouth, VA*
Commander, Naval Surface Forces*
Commander, Naval Surface Forces/Commander, Naval Air Forces, Inspector General*
Naval Activities and Fleet Vessels as shown below:
Naval Medical Center, Portsmouth, VA*
Mid-Atlantic Regional Maintenance Center, Norfolk, VA*
Carrier Airborne Early Warning Squadron, VAW-120, Norfolk, VA *
Transient Personnel Unit Norfolk, VA *
Fleet Readiness Center, Norfolk, VA *
Commander Naval Special Warfare Development Group, Virginia Beach, VA*
Sewells Point Safety Office, Naval Station Norfolk*
Fleet Readiness Center Oceana, Virginia Beach, VA*
Naval Computer and Telecommunications Area Master Station Atlantic, Norfolk, VA *
Naval Air Station Jacksonville, FL*
Fleet Readiness Center Southeast, Jacksonville, FL*
Naval Station Mayport, FL*
Strategic Weapons Facility Atlantic, Kings Bay, GA*
Fleet Area Control and Surveillance Facility ,Jacksonville, FL*
Helicopter Strike Squadron 41, San Diego, CA*
Transient Personnel Unit San Diego, CA*
Southwest Regional Maintenance Center, San Diego, CA*
Naval Special Warfare Center, San Diego, CA*
Naval Medical Center, San Diego, CA*
Seal Delivery Vehicle Team One, Pearl City, HI*
Naval Station Pearl, Pearl Harbor, HI*
Naval Security Group Activity Kunia , HI*
Commander, Pacific Fleet, HI*
EXHIBIT C: ACTIVITIES VISITED AND/OR CONTACTED
41
NAVAL STATION NORFOLK VA:
USS COLE
USS GONZALEZ*
USS HAWES
USS WASP
USS HARRY S. TRUMAN*
USS STOUT
LITTLE CREEK AMPHIBIOUS BASE, VA:
USS ASHLAND
USS CARTER HALL
USS MONSOON*
USS OAK HILL
USS SQUALL*
USS TEMPEST
USS WHIDBEY ISLAND*
MAYPORT FL:
USS CARNEY
USS DOYLE*
USS GETTYSBURG
USS HALYBURTON*
USS HUE CITY*
USS JOHN L. HALL*
USS MCINERNEY
USS PHILIPPINE SEA*
USS SIMPSON
USS STEPHEN W. GROVES
USS TAYLOR
SAN DIEGO
USS BENFOLD
USS BONHOMME RICHARD
USS CAPE ST. GEORGE
USS CURTS
USS GRIDLEY
USS HIGGINS*
USS HOWARD
USS JARRETT*
USS NIMITZ*
EXHIBIT C: ACTIVITIES VISITED AND/OR CONTACTED
42
USS PEARL HARBOR*
USS PELELIU*
USS RONALD REAGAN
USS SAMPSON
PEARL HARBOR HI
USS REUBEN JAMES
USS CHAFEE
USS CHOSIN*
USS CROMMELIN*
USS OKANE*
USS PORT ROYAL*
USS RUSSELL*
*Activities/Ships visited
FOR OFFICIAL USE ONLY
43
FOR OFFICIAL USE ONLY
Appendix 1:
Consolidated Management Response
FOIA (b)(6)
FOIA (b)(6)
APPENDIX 1: CONSOLIDATED MANAGEMENT RESPONSE
44
APPENDIX 1: CONSOLIDATED MANAGEMENT RESPONSE
45
APPENDIX 1: CONSOLIDATED MANAGEMENT RESPONSE
46
APPENDIX 1: CONSOLIDATED MANAGEMENT RESPONSE
47
APPENDIX 1: CONSOLIDATED MANAGEMENT RESPONSE
48
APPENDIX 1: CONSOLIDATED MANAGEMENT RESPONSE
49
APPENDIX 1: CONSOLIDATED MANAGEMENT RESPONSE
50
APPENDIX 1: CONSOLIDATED MANAGEMENT RESPONSE
51
APPENDIX 1: CONSOLIDATED MANAGEMENT RESPONSE
52
FOR OFFICIAL USE ONLY
53
FOR OFFICIAL USE ONLY
Appendix 2
Additional Management Response to
Selected Recommendations
FOIA (b)(6)
FOIA (b)(6)
FOIA (b)(6)
APPENDIX 2: ADDITIONAL MANAGEMENT RESPONSE TO SELECTED RECOMMENDATIONS
54
APPENDIX 2: ADDITIONAL MANAGEMENT RESPONSE TO SELECTED RECOMMENDATIONS
55
FOR OFFICIAL USE ONLY
56
FOR OFFICIAL USE ONLY
FOIA (b)(6)
APPENDIX 2: ADDITIONAL MANAGEMENT RESPONSE TO SELECTED RECOMMENDATIONS
57
APPENDIX 2: ADDITIONAL MANAGEMENT RESPONSE TO SELECTED RECOMMENDATIONS
58
APPENDIX 2: ADDITIONAL MANAGEMENT RESPONSE TO SELECTED RECOMMENDATIONS
59
APPENDIX 2: ADDITIONAL MANAGEMENT RESPONSE TO SELECTED RECOMMENDATIONS
60
FOR OFFICIAL USE ONLY
61
FOR OFFICIAL USE ONLY
FOIA (b)(6)
APPENDIX 2: ADDITIONAL MANAGEMENT RESPONSE TO SELECTED RECOMMENDATIONS
62
APPENDIX 2: ADDITIONAL MANAGEMENT RESPONSE TO SELECTED RECOMMENDATIONS
63
APPENDIX 2: ADDITIONAL MANAGEMENT RESPONSE TO SELECTED RECOMMENDATIONS
64
FOR OFFICIAL USE ONLY
FOR OFFICIAL USE ONLY
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